John Kitzhaber

For there is another kind of violence, slower but just as deadly, destructive as the shot or the bomb in the night. This is the violence of institutions; indifference and inaction and slow decay. This is the violence that afflicts the poor, that poisons relations between men because their skin has different colors. This is a slow destruction of a child by hunger, and schools without books and homes without heat in the winter.

Robert Kennedy, April 5, 1968

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Introduction

This is an early draft of a paper I presented to the “Roundtable for Education and Healthcare” convened by leaders at CareOregon and the Gladstone School District to “explore collaborative, innovative approaches to meeting the needs of the children and families we collectively serve.”  The goal is to develop a strategy, funding and delivery system that can effectively and sustainably move public, private and philanthropic resources upstream to address the root causes that undermine the success of children and families in our state. Since then, the group has refined the paper and plans to seek funding from the legislature to implement several pilot projects to develop the “blueprint” for a childhood success system that can then be scaled across Oregon.

John A. Kitzhaber, M.D.

 

OVERALL CONCEPT

Ensuring Every Child has an Equitable Opportunity to Succeed by:

• Addressing the conditions of injustice and systemic racism, exacerbated by the Pandemic, that undermine success and lead to structural social inequities and health disparities and,
• Empowering and investing upstream in those most impacted by co-creating whole-person, integrated supports and services for children, families, communities, and our workforce by,
• Creating partnership between health, education and social service sectors, in collaboration with local community leadership to,
• Build and test scalable, trauma-informed model systems with an asset-based approach to create conditions where all children, families and communities are afforded an equitable opportunity to succeed.

 

BACKGROUND AND CURRENT LANDSCAPE

American Rescue Plan Act of 2021 (ARPA)

The state of Oregon is now looking at a huge infusion of revenue from the American Rescue Plan Act (H.R.1319 – American Rescue Plan Act of 2021, signed into law by President Biden on March 11, 2021) that will arrive over the next few months, including over $4 billion for state and local government.

The ARPA package[1] intends to address the ongoing impact of the COVID-19 pandemic on individuals and families, on the economy, public health, and state and local governments. Funding provisions in ARPA offer support for direct COVID-19 response (e.g., vaccinations, testing, treatment, prevention) and recovery (e.g., nutrition assistance, school and child care program funding, mental health services), as well as broader economic, social, and scientific investments (e.g., small business assistance, scientific research, and capital projects).

Over the next few months, Oregon expects to see an infusion of over $4 billion from the ARPA for state and local governments. The Oregon Health Authority (OHA) intends to use a portion of its funds from the ARPA to meet the strategic goal of “ending health inequities in our state by 2030.” To help achieve this goal, “OHA and community partners co-created the State Health Improvement Plan, which identified the following priorities:

• Institutional bias
• Adversity, trauma and toxic stress
• Behavioral health
• Economic drivers of health
• Access to equitable preventive healthcare

While all of these investments make sense, most of them are going into existing structures and delivery systems. And many of them will be one-time investments. To meet the goal of “ending health inequities in our state by 2030,” however, we must effectively address the socioeconomic inequities that drive them, including systemic racism. These are root causes, and addressing them requires an integrated, collaborative delivery model that can sustain investments in a given child and their family over an 8 to 10-year period.  

Goal

To ensure that every child has an equitable opportunity to succeed.

We want to reach a point where ZIP Code, ethnicity, race or language are no longer indicators of future success (or lack thereof). The seeds that undermine successful children are planted very early, even before birth. These are the same root causes that lead to the health disparities and socioeconomic inequality that continue to plague our state and our nation.

Children’s Contextual Ecosystem

Children exist in an ecosystem that includes their family and their community. This means that to meet our goal, we must focus not only on the child, but also on the environment in which the child lives.[2]

The World Health Organization defines health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” If we could write a prescription for America that would surely be it.  And if we could fill that prescription by spending more money on the U.S. health care system, we would already be there. Yet, fifty years of evidence tells us that the promise of health care for all Americans is not the same as a healthy America. In 1968 the U.S. was spending 6.2% of its GDP on health care. Today we are spending almost 18%, yet life expectancy has declined three years in a row, driven largely by inequality and economic hardship, particularly in working class America.

Although not apparent at the moment people need access to medical care, our health care system plays a relatively minor role when we look at those factors that have the greatest impact on lifetime health status. Far more important are the “social determinants of  health: healthy pregnancies, affordable housing, good nutrition, safe communities, education and living wage jobs. These are the pillars of family stability, success—and of health.

One of the most powerful social determinants of health, one that dramatically undermines the opportunity for a child to succeed, is growing up in a family under stress—and two of the most significant factors that lead to stress and family dysfunction are systemic racism and poverty.

Understanding Adverse Experiences — The “Pair of ACEs”[3]
We know that there is a strong correlation between the level of traumatic stress in childhood and poor physical, mental and behavioral outcomes later in life—including behavioral and learning problems, risky behavior, school failure, the early adult onset of chronic disease, mental illness, and subsequent involvement in the social support system and often in the criminal justice system, and early death.

Traumatic stress in children results from two sets of adverse experiences: Adverse Childhood Experiences and Adverse Community Environments—the pair of “ACEs.”  Adverse childhood experiences include a parent with a mental health condition and/or substance use disorder, physical or emotional neglect, physical, verbal or sexual abuse, domestic violence and loss of a parent through divorce, abandonment or incarceration. These Adverse Childhood Experiences, in turn, are often the result of Adverse Community Experiences, which include systemic racism, poverty, food and housing insecurity, lack of economic opportunity and upward mobility, and communities that are not safe.

It is now also recognized by the field of epigenetics that chronic stress during pregnancy can alter genetic expression in the unborn child. These prenatal experiences create templates for how the child will process experiences in the future—increasing the risk of emotional problems, behavioral disorders and learning disabilities—thus passing the factors that can undermine childhood success from generation to generation. This is particularly true for Black Americans and Indigenous Americans, and other communities of color, who have experienced the chronic stress of systemic racism, discrimination and racial bias for centuries.

The Generational Cycle of the ACEs

 

BREAKING THE CYCLE AND BUILDING COMMUNITY RESILIENCE  

In every child who is born, under no matter what circumstances, and of no matter what parents, the potentiality of the human race is born again.” — James Agee

Ensuring that every child has an equitable opportunity to succeed, involves breaking the generational cycle driven by the social, economic and health consequences of the ACEs. To do so, we must change the life arc of risk factors in children by focusing our efforts as far upstream as possible—ideally even before conception, but at a minimum during pregnancy—where we can gain the greatest leverage and best longterm outcomes. 

A Waypoint Analogy

Airplanes on long trips are constantly being taken off course by cross winds, weather and other factors.  Any long flight has a series “way points” to guide the necessary course corrections required to arrive at the destination. Suppose an airplane takes off from Portland on a flight to New York City and the flight is a few degrees off course when it clears the runway at PDX. Without a correction in the flight plan, the plane will end up somewhere north of Montreal, Canada. Once the error in trajectory is discovered, it is much easier to make the course adjustment at a way point over Boise, Idaho than over Chicago. And at some point, the course correction becomes so extreme that it becomes nearly impossible to reach the original destination.

Children also have “way points” in their development that indicate whether they are on a course to success. These include certain physical, social and emotional developmental way points in the early years of life, then Kindergarten readiness, reading at level in third grade,[4] on track to graduate in the ninth grade,[5] etc. These way points represent a continuum of child development and the earlier we intervene in the life arc of a child who is heading off course, the more successful we will be (and the less costly both in terms of the investment involved and the avoided cost later on). 

Success Investment Windows

We can identify four distinct windows (way points) for “success investments” (SI):

1. First 1000 days — conception to age 2 [normal physical, social, emotional development]
2. Age 3-5 — Preschool through Kindergarten [Kindergarten readiness/Ready to Learn]
3. Age 6-8 — Grades 1 through 3 [Reading at level in 3^rd grade]
4. Age 9-13— Grades 4-8 [On track to graduate from high school]

Given the fact that stress during a woman’s pregnancy can alter genetic expression, leading to problems in the emotional, behavioral and physical development of the child, the first 1,000 days is the optimal success investment window in which to start to break the cycle. This is the period of time during which the foundations of optimum health, growth, and neurodevelopment are established. Then, investments must follow the child and his or her family through the subsequent investment windows.

 

THE FOUR KEY ELEMENTS OF SUCCESS

Breaking the generational cycle of the ACEs, which compromises the ability of children to succeed, requires a longterm strategy built on four central elements:

1. Identifying risk factors in children’s lives that can result in trauma and adverse experiences.

• Understanding the evidence-based and community driven treatments, supports and interventions that can prevent, address or protect children from these risk factors and positively alter the life arc of the child.

• Securing the resources necessary to sustain these treatments, supports and interventions over time.

• Having in place an integrated, aligned and collaborative delivery system that can effectively and efficiently deliver those treatments, supports and interventions to children and families, in a way that is ethnically, culturally and linguistically appropriate.

Elements 1 and 2: Identifying risk factors in children / Implementing evidence-based and community driven approaches

In terms of meeting the first two challenges—identifying risk factors in children and families, and understanding those things that can help make them successful—we are fortunate that the Center for Evidence-Based Policy, which is housed at the Oregon Health & Science University, has developed a longitudinal dataset, the Oregon Child Integrated Dataset (OCID that can help guide this important work.[6]

This project has matched data on every child born in Oregon since 2000, and their known parents, with data from publicly-funded services for those children and families (such as child welfare & foster care, Medicaid services, early childhood investments (such as Head Start), K-12 information, and juvenile corrections.

This is a remarkably rich dataset, with the oldest cohort now 21 years of age. Since there are around 45,000 children born each year in Oregon, this database now includes almost 950,000 people. (By comparison, the ACE study tracked 17,000). And this is all Oregon data. Without going into great detail, this data provides a critical—and heretofore unavailable—picture of the nature, prevalence and implications of chronic childhood stress and trauma. It can provide us with a “risk/success profile” that is highly predictive of future outcomes. This, in turn, will allow us to match children and families with the treatments, supports and interventions that can prevent, address or protect children from these risk factors and positively alter the life arc of the child. This data can also help evaluate the effectiveness of our programs, supports and interventions.

Element 3: Long term, stable funding

Breaking the generational cycle of the ACEs will require securing the resources necessary to sustain evidence-informed approaches (e.g., treatments, supports, interventions, and other promotion/prevention strategies) over time. To be successful, adequate funding must last for at least six years (three biennia), following the child and his or her family from conception through age 5 (SI windows 1 and 2). Ideally, the investments would be maintained for ten years (five biennia), following the child and his or her family until age 6 through age 9 (SI window 3 and beginning of SI 4). Given the intense competition for limited public resources, it will be difficult to maintain funding over multiple biennia unless the goal we are pursuing is built on a solid foundation, and with such broad support across Oregon, that it can continue to move forward and be sustained regardless of changes in the executive branch or partisan changes in the make-up of the legislature.

The political challenge in making these long-term investments is that their impact will not become apparent over the course of a few years—yet to be effective, they must be sustained over several budget cycles. Furthermore, the political imperative traditionally sustains existing institutions and often discourages investing in new initiatives, even those that could make these institutions more effective.

So, a central part of the strategy needs to include building a new coalition that can elevate the importance of these investments. The fact is that ensuring the success of our children by addressing the sources of childhood trauma and adverse experience, is not only a health care issue and an education issue, it is also a public safety issue and a social support issue. If we want better educated children, it starts here. If we want to reduce the size and cost of the criminal justice system, it starts here. If we want to reduce chronic disease, substance use disorder and the cost of our social support system, it starts here.

Element 4: Child Success Delivery System

Breaking the generational cycle of the ACEs requires having in place an integrated, aligned and collaborative delivery system that can effectively and efficiently deliver those treatments, supports,  interventions, and other protective/prevention strategies to the right children and families, in a way that is ethnically, culturally and linguistically appropriate.

While adequate, sustained funding will be a challenge, the far greater challenge is that we lack an effective, integrated and collaborative community-based delivery system. The range of culturally and linguistically specific treatments, supports and interventions that may be required for a given child and his or her family might include:

• Prenatal care, health care – integrated physical/mental health and dental care
• Parenting skills
• Affordable child care
• Quality educational experiences
• Nutrition and health awareness
• Safe and stable housing
• Transportation
• Emotional support and mental health
• Behavior health/substance use disorder services
• Job training and employment
• Provide publicly-funded transitional jobs for families with children
• Income supports
  • Enhanced EITC
  • Enhanced child care tax credit

In any given community, there are often scores of different agencies, programs, community-based organizations, foundations and institutions involved in providing these services and supports. In many cases, these diverse entities are dealing with only one or two of the risk factors, but not as a constellation and often not customized to the needs of a specific child and their family. And they are certainly not aligned or coordinated, they do not leverage one another and therefore are far less than the sum of their parts. Without a clear, well defined, integrated and collaborative delivery system, these multiple entities can devolve into a kind of competition in which collaboration is sacrificed to a particular program or funding stream, turf issues abound, and organizational survival takes precedent over the larger purpose for which the organizations were created in the first place. We lose adhesiveness and common purpose.

Children wander through this “system” seeking services, rather than having the services follow the child and their family. Programs are fragmented, often operating in silos and there are gaps. There may or may not be coordination in the hand-offs between programs and services. While we can show positive results from various individual programs, we are not narrowing the opportunity gap across the population as a whole. For example, thee percentage of Americans living in poverty when the War on Poverty was underway was about 15 percent, and it is about 15 percent today.[7] In many cases this is a “last mile” problem—actually getting the right services to the right children and families, at the right time, in the right amount and for long enough to make a difference. In a very real sense, we are “program rich and system poor”, we are “failing the community one success at a time.”

The national Campaign for Grade Level Reading, which has now engaged 43 states, 344 communities and 3900 local organizations, illustrated the problem. Although this effort is showing progress in moving the needle within individual programs, double-digit gaps persist in every state and almost every community. Ralph Smith, the Managing Director of the organization, attributes this, in large part, to the fragmentation and duplication of efforts, the proliferation of silos and the difficulty of accessing and effectively utilizing data. That is exactly what we are facing here in Oregon.

 

CONCEPTUAL DESIGN OF A CHILD SUCCESS DELIVERY SYSTEM

Notwithstanding the billions of dollars coming our way for expanded health care coverage, housing, child care, workforce development, behavioral health, pre-K and many other worthy and long overdue investments, all of these resources are funding a siloed “delivery system” that focuses on programs, organizations, agencies and institutions, rather that on the children and families that all of these entities are ostensibly supposed to be serving. All the money in the world will not break the generational cycle of the ACEs or give each and every child a safe space in which to grow and thrive and become all that they can be—unless this massive infusion of public dollars, increasingly borrowed from future generations, is focused on the children themselves.

The missing link here is an integrated, collaborative Child Success Delivery System, designed to break the generational cycle of ACEs by addressing the sources of trauma and adverse experience, from the first thousand days of life, through the age of 5 (investment windows 1 and 2)—with a warm hand off to our system of public education—and with the investment continuing to follow the child and their through age 9 (SI window 3 and beginning of SI 4). During the first 1000 days, most of the investments will be focused on health and social factors. As the child grows older, more of the investment will move toward education.

Creating the conceptual design for a Child Success Delivey System will be by far the most difficult—and I would argue, most important—component of this work. Why? Because it will require that dozens of programs, organizations, agencies and institutions—and those who work in them—subordinate their organizational, programmatic and institutional interests to serve a larger common purpose: the long-term success of children and families as they move across a very siloed landscape.  A strong sense of common purpose, of shared mission is the one essential ingredient necessary to build community – and it is community that gives us the adhesiveness that holds us together and allows us to act in concert for the common good.

We need to focus on why we lack the kind of childhood delivery system described above, and the key design elements needed for success. It requires approaching the challenge outside of the traditional programmatic, organizational and institutional mindset in which we normally operate—a frame of reference often strongly influenced by funding—and one which limits our creativity. We need to start by simply asking, “what will it take” to ensure that all children are surrounded by safe, trusting  communities, and warm, nurturing relatioships with parents or caregivers.

In short this is an “if anything were possible” exercise—not initially a program or service discussion. For example: “If anything were possible,” how do we ensure that all of our children:

• Have a calm and nurturing in-utero experience
• Are welcomed and wanted by a safe and emotionally stable adult
• Have at least one adult to attach to and who can be relied upon – someone who is predictable, constant, warm, and loving
• Have basic needs met and have access to basic resources that are predictable and constant
• Feel safe and loved throughout childhood
• Are protected from violence and racism, and are consoled when bad things happen

How do we make sure that happens? What does it look like? We need to start with that question and stay with the child and their family as we design a community-based system that can achieve those outcomes and values, especially in the first 1000 days of life. This “blueprint” for a childhood success system is the conceptual design we need. It is the thing that is lacking, the missing link.

Once this foundational work has been completed, demonstration models can set up to offer the proof of concept—with each model implementing the conceptual design in a way that reflects local circumstances and empowers those most affected in that particular community. This, then, would allow us to begin to scale the model.

Undertaking this work now will be complicated by the need to address the immediate human impacts of the pandemic on children. At the same time, we simply cannot continue to defer addressing root causes because of immediate challenges. If we do we will continue to operate be behind the curve and fall further and further behind.

There are over 45,000 children born each year in Oregon, and we cannot afford to lose a single one. Yet every day that passes without an effective way to ensure that each and every one of these children truly has an equitable opportunity to succeed, some will be lost. And every time that happens, we are all diminished and we lose a little bit more of the soul of our state. It is imperative that we act on this now—our children can’t wait … and neither should we.

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Health care and poverty are inseparable issues and no program to improve the nation’s health will be effective unless we understand the conditions of injustice which underlie disease. It is illusory to think that we can cure a sickly child and ignore his need for enough food to eat.

Robert Kennedy, 1968

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[1] https://www.congress.gov/bill/117th-congress/house-bill/1319/text

[2] Early Relational Health: Community Level Strategies for Supporting the Psychosocial Health of Infants, Toddlers, and Caregivers – Gary Willis | Center for the Study of Social Policy (cssp.org)

[3] https://www.cdc.gov/violenceprevention/aces/fastfact.html

[4] Third grade has been identified as important to reading literacy because it is the final year children are learning to read, after which students are “reading to learn.” If they are not proficient readers when they begin fourth grade, as much as half of the curriculum they will be taught will be incomprehensible.

[5] “On track” means a student has enough credits to progress to the next grade level and has been present for at least 90 percent of enrolled school days. On-track students are more than three and one-half times more likely to graduate from high school in four years than off-track students. 

[6] This is not intended to suggest that OCID is the only resource available to us, or that there are not issues/questions about who is included, data collection methodologies and how the data would be used.

[7] Carmen DeNavas et al., “Income, Poverty, and Health Insurance Coverage in the United States: 2010” (Washington, DC: U.S. Department of Commerce, 2011), 15.